SMSNA Membership APPLICATION

This form can be used to apply for SMSNA membership. Your membership application will be reviewed by the Board and presented to the SMSNA membership at the next SMSNA business meeting. If approved, you will become a member for 2017. At the end of each calender year, a tacit renewal of your membership is applicable, for which you will be invoiced at the end of the running year.

All data submitted on this form will be processed on a Secure Server (SSL), which is owned and maintained by the company managing the SMSNA "Status Plus". For more information please contact us by phone (952) 683 1917 or e-mail info@smsna.org.

On-line Membership Application Form - Step 1 of 3

 
Gender:  M   F    
Title (Prof., Dr., etc.):   
First name:   
Middle name:   
Last name:   
Suffix:   
Degrees (MD, PhD, etc.):   
Institution/organization:   
Department:   
Cell phone:   
Skype name:   
Date of birth:   
AUA ID#:   
Personal website/profile:   
On-line CV (link):http://
E-mail 1 (main):   
E-mail 2 (alternative):   
 
Prefered mailing address:  office    home   
 
Office address:   
   
City:   
Province/State:   
Zip code:   
Country:  
Work phone:   
Extension:   
Work fax:   
Corporate website:   
 
Home address:   
   
City:   
Province/State:   
Zip code:   
Country:  
Home phone:   
  

Postgraduate Training


Residency: (institution, location, dates)
Fellowship: (institution, location, dates)

SMSNA Membership 2017


SMSNA Membership is valid for one full calender year (January 1st to December 31st, 2017). More information about the different membership benefits and categories can be found here.

Membership Category Membership Fee
SMSNA Active Membership 2017 $   175
SMSNA Corresponding Membership 2017 $   175
SMSNA Student Membership 2017* $   0
* To qualify for student membership, written proof of your status as a student is required when applying (for example, a copy of your student ID or a letter declaring your status, dated and signed on your institution's letterhead/stationary). Upon submitting your application, please also send a scan of the supporting documentation by e-mail to info@smsna.org or fax it to: (612) 808-0491. NOTE: Your student membership application is not considered complete without supporting documentation and will not be processed until such proof is duly received.
 

ISSM Membership & Journals (JSM/SMR) Subscription


SMSNA Active Membership includes membership in the ISSM at no additional charge, which also includes an online subscription to the Journal of Sexual Medicine (monthly) and Sexual Medicine Reviews (quarterly). With this subscription you have full online (digital) access to all journal articles. For a small additional fee of USD 25 you can also subscribe to receiving the printed copies of both journals. You can indicate your choice below:

Journal Subscription:  

Online access to JSM+SMR (NO EXTRA CHARGES)   
Printed copies + online access to JSM+SMR (+USD 25)   
 

Payment


I will pay by:  

Credit Card (preferred)  
Check   

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